evaluation of the incidental solitary liver...

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Lewis R. Roberts, PhD, FAASLD

Evaluation of the Incidental

Solitary Liver Lesion

Postgraduate Course:

Challenges in Management of Common Liver Diseases

347

© 2016 AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES

WWW.AASLD.ORG 2

Questions for Reviewers:

1. Is it ok to leave out simple cyst

and abscess slides – 23,24,25?

2. Are LIRADS slides needed –

30,31?

3. Any other suggested changes?

348

A 39 year old female with a 2 cm solitary lesion

on ultrasound and normal liver chemistries

Key Questions/Content Focus:

• Present an algorithm for investigation of

incidental solitary solid liver lesions.

• How does one differentiate a benign from a

malignant lesion?

• Do adenomas and focal nodular hyperplasia

need to be followed and if so, how? © 2016 AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES

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Case

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Objectives

• Clinical classification of liver masses

• Evaluation of liver mass lesions

• Common benign mass lesions • Clinical features • Imaging characteristics • Optimal management

• Common malignant mass lesions • Hepatocellular Carcinoma • Cholangiocarcinoma • Metastases from other Primary Sites

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Three Categories of Liver Masses

1. Benign lesions usually requiring no further intervention

2. Benign lesions requiring further investigation and therapy

3. Malignant lesions requiring appropriate management

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1. Benign lesions usually requiring no further intervention

• Cavernous hemangioma

• Focal nodular hyperplasia

• Simple cyst

• Focal fatty change or sparing

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2. Benign lesions requiring further

investigation and therapy

• Hepatic adenoma and adenomatosis

• Biliary cystadenoma

• Hepatic abscess – pyogenic or amebic

• Echinococcal cyst

• Granulomatous inflammation

• Inflammatory pseudotumor

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3. Malignant lesions requiring appropriate

management

• Metastases from other primary sites

• Hepatocellular carcinoma

• Cholangiocarcinoma

• Biliary cystadenocarcinoma

• Lymphoma

• Hepatic angiosarcoma

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Clinical Approach to Liver Mass Lesions

• Symptoms

• Physical examination

• Laboratory studies

• Imaging characteristics: Ultrasound, CT,

MRI (especially with newer hepatobiliary

contrast agents)

• Need for biopsy

• Optimal management 355


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Phasic Vascular Perfusion of the Liver

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Cavernous Hemangioma: Histology

Large hemangiomas

may have areas of

thrombosis, scarring,

and calcification

Network of vascular spaces separated by thin, fibrous stroma

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Cavernous Hemangioma

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Pre-contrast

Arterial phase

Venous phase

Peripheral nodular arterial phase enhancement,

with fill-in to the center in the venous phase

45 y o F with a Liver Mass

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Focal Nodular Hyperplasia: Histology

• Benign reaction to congenital arterial malformation

• Vascular stellate scar and septal fibrosis

• Polyclonal hepatocytes and functioning bile ductules

• Aspirates indistinguishable from adenoma 361

MRI of Focal Nodular Hyperplasia

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Sodium Gadoxetate MRI for

Distinguishing FNH from Adenoma

• Brightly enhancing in arterial phase

• Homogeneous enhancement with central scar

• Isointense in portal venous phase

• Retained intensity in the hepatobiliary phase supports the diagnosis of FNH

Arterial Portal Venous Hepatobiliary

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Histopathology of Adenoma

Monoclonal hepatocytes

Prominent “naked” arteries

No normal portal tracts or bile ducts

Adenoma

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β-catenin Exon 3 Mutated Adenomas

have Higher Risk of Malignancy

Normal Membrane

Staining

Positive Nuclear

Staining 365

MRI of Hepatic Adenoma

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Gadobenate Dimeglumine MRI for

Distinguishing FNH from Adenoma

• Heterogeneous arterially enhancing mass • Isointense in portal venous phase • Decreased intensity in the hepatobiliary

phase suggests HNF1A mutated adenoma • Inflammatory and β-catenin mutated

adenomas may retain contrast

Arterial Portal Venous Hepatobiliary

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Management of Hepatic Adenomas

• Follow up 6 mo, q 1 yr x 5 yrs, then q 2 yrs

• High Risk: Resect

• Lesions ≥ 5 cm (or increasing size)

• Hemorrhage

• Male Gender (increased malignant risk)

• β-Catenin mutated adenomas

• Older females with no history of OCP use

• Low Risk: Stop OCPs, lose weight

• Young Females, lesions < 5 cm on OCP

• Follow w US q 6-12 weeks during pregnancy

• Alternatives to Resection: RFA, embolization 368

Imaging Characteristics of Liver Cysts

Ultrasound

• Best test

• No internal echoes

• No flow on color flow

or duplex Doppler

• Through transmission

• Well-defined posterior

walls

• May have thin

echogenic septa 369

Symptomatic Cyst in a 72 y o F with Painless Jaundice and Leg Edema

Presentation

1 year after cyst aspiration

& EtOH sclerosis 2 years later

370

Pyogenic Liver Abscess

• Rupture or leak of

bile duct or bowel

• Biliary stenting,

instrumentation, or

chemoembolization

• Increased risk in

diabetes mellitus

• Biliary: enteric gram

-ves & enterococci

• Other sites: mixed

aerobic & anaerobic

41 yo F with new diagnosis of type 1 diabetes mellitus with ketoacidosis and liver mass

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Imaging Characteristics of Focal Fat:

65 y o Woman Referred for Presumed

Gallbladder Adenocarcinoma

Ultrasound Hyperechoic

T1 Weighted In & Out of Phase

3 Month Follow-Up

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• Epidemiology:

• Fatty liver is increasingly common

• Focal fatty infiltration looks like a mass

• Also focal sparing in diffuse fatty infiltration

• Associations:

• Obesity

• Diabetes mellitus

• High alcohol consumption

• Altered metabolism due to chemotherapy

Focal Fat or Fat Sparing

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Hepatocellular Carcinoma

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Non-Invasive Diagnosis: Arterial Enhancement, Venous Washout, Capsule and Threshold Growth

Arterial

Portal

Late venous phase 375

LIRADS System for HCC Diagnosis

Threshold Growth

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Lesion

Characteristics

LIRADS System for HCC Diagnosis

Schema

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20 year old F with Long History of Vague Symptoms and Large Liver Mass

Fibrolamellar Subtype of HCC

Arterial phase Portal phase

• Young females

• Lymph node metastases

• Aggressive surgery recommended

• DNAJB1-PRKACA Chimeric Transcripts 378

Intrahepatic CCA

Perihilar CCA

Distal CCA

Image Courtesy of Dr. Gregory Gores

Gall bladder

Cystic duct

Pancreas

Cholangiocarcinoma (CCA)

Small

intestine

Liver

Bile duct

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Imaging of Cholangiocarcinoma

Intrahepatic Cholangiocarcinoma

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Imaging and Pathology of CCA

Intrahepatic Cholangiocarcinoma

Histopathology Peripheral

Enhancement

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Case

A 39 year old female with a 2 cm solitary lesion

on ultrasound and normal liver chemistries

Key Questions/Content Focus:

• Present an algorithm for investigation of

incidental solitary solid liver lesions.

• How does one differentiate a benign from a

malignant lesion? Imaging and/or biopsy

• Do adenomas and focal nodular hyperplasia

need to be followed and if so, how? Follow

adenomas – 6 mo, q 1 yr x 5 yrs, then q 2 yr 382


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Summary

• History, physical, and laboratory tests are important in the evaluation of liver masses

• Imaging techniques allow distinction between most benign and malignant liver masses

• Repeat imaging after an interval or biopsy when the diagnosis remains uncertain

• The commonest conundrum is the distinction between FNH and adenoma

• Focal fat or sparing in a fatty liver frequently masquerade as a mass

• HCCs show distinct differences from adenocarcinomas such as cholangiocarcinoma

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Thank You for Your Attention!

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Questions for Reviewers:

1. Is it ok to leave out simple cyst

and abscess slides – 23,24,25?

2. Are LIRADS slides needed –

30,31?

3. Any other suggested changes?

385

evaluation of the incidental solitary liver...

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